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[LECTURE
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[Lecturer]
DD Month 2016
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Types of FUO
Classic FUO
LEGEND
Lecture Powerpoint, Audio, Textbook
Nosocomial FUO
Definition
Fever of Unknown Origin (FUO) is defined as any febrile illness
without initially obvious etiology. Most would be resolved before
diagnosis or is used to lead on a diagnosis. FUO excludes immunecompromised patients because they require an entirely different
diagnostic and therapeutic approach.
NeutropenicFUO
HIV-associated FUO
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Classic FUO
remember that FUO is far more often caused
by an atypical presentation of a rather common
disease than by a very rare disease.
Signs and Symptoms:
Endocarditis
Diverticulitis
Vertebral osteomyelitis
EPTB
The range of FUO etiologies has evolved over time as a result of changes
in the spectrum of diseases causing FUO, the widespread use of
antibiotics, and the availability of new diagnostic techniques.
Increase in diagnostic failure rate is due to the establishment of the
diagnosis prior to the 3 weeks illness duration even with advanced
technological screening techniques (CT and MRI). Also, a patient with
FUO but without a diagnosis has less aggressive diagnostic approach and
is relevant with recurrent fever (repeated episodes of fever interspersed
with fever-free intervals of at least 2 weeks and apparent remission of the
underlying disease) would have <50% etiologic diagnosis.
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Important considerations
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Neoplasm
Elderly: giant-cell arteritis, TB, colon CA
Miscellaneous: drug fever, pulmonary embolism,
factitious fever
As the duration of fever increases, the likelihood of an
infectious cause decreases
Malignancies
Lymphoma
Lymphoma
Lymphoma
Renal cell carcinoma
Hepatocellular carcinoma
Collagen Vascular Diseases
SLE, mixed connective tissue disease
Giant cell arteritis/polymyalgia rheumatica, ankylosing
spondylitis
Rheumatic fever
Polymyositis, rheumatoid arthritis
Drug Fever
No characteristic fever pattern was observed.
Maximum temperatures ranged from 38C to 43C
The mean lag time between initiation of a drug and the
onset of fever was 21 days, but lag times varied
considerably.
Alpha methyldopa and quinidine were the two drugs
most commonly implicated, but antimicrobials (as a
group) were responsible for the largest number of
episodes.
Allopurinol, carbamazepine, lamotriginephenytoin
Factitious fever
Fraudulent fever
The patient is normothermicbut manipulates the thermometer
Adult Causes
Module #, Lecture #
Fever in
Rectal abscesses
Typhilitis
Imaging very important
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o Phlebitis
Pressure ulcers
Prognosis
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History
Recent travel, exposure to pets and other animals, the
work environment, and recent contact with people
exhibiting similar symptoms.
family history for possible hereditary causes of fever
past medical history -for any previously diagnosed
conditions, such as lymphoma, rheumatic fever, or intraabdominal disorders, complications or reactivation
complete list of the patients medications
Verification of fever and fever pattern
Physical Examination
nodular or weakly pulsatile temporal artery of temporal
arteritis
telltale oral ulcers of disseminated histoplasmosis or
Behcets syndrome
choroid granuloma or epididymal nodule of
extrapulmonary tuberculosis
testicular nodule of polyarteritis nodosa
vague rectal fluctuance of a perirectal abscess
search for lymphadenopathy
Treatment
Empiric Treatment
Steroids
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Differential Diagnosis
Treatment
Antibiotics and Anti-tuberculous Therapy
Irrevocably diminish the ability to culture fastidious bacteria or
mycobacteria. Hemodynamic instability or neutropenia is a
good indication for empirical antibiotic therapy. If the fever
does not respond after 6 weeks of empirical anti tuberculous
treatment, another diagnosis should be considered.
Rare (nonspecific):
Q fever
Whipples disease
Summary
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Scintigraphy
Noninvasive method allowing delineation of foci in all parts of the body
on the basis of functional changes in tissues which plays an important
role in the diagnosis of patients with FUO in clinical practice.
Conventional scintigraphic methods used in clinical practice are Gacitrate scintigraphy and In- or Tc-labeled leukocyte
scintigraphy. Focal infectious and inflammatory processes can also be
detected by several radiologic techniques, such as CT, MRI, and
ultrasound. Because of the lack of substantial pathologic changes in the
early phase, infectious and inflammatory foci cannot be detected at this
time.
CT and MRI routinely provide information only on part of the body,
while scintigraphy readily allows whole-body imaging. Scintigraphic
techniques do not directly provide a
definitive diagnosis, they often identify the anatomic location of a
particular ongoing metabolic process and, with the help of other
techniques such as biopsy and culture, facilitate timely diagnosis and
treatment.
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